10 Years Since HITECH: The Good, the Bad and the Ugly

The following is a guest article by John D’Amore, President and Chief Strategy Officer, Diameter Health.

Almost every article on the 10 years since the passage of the HITECH Act mentions the over $35 billion spent to incentivize the implementation of electronic health records. Most go on to conclude either “We failed!” because there are still plenty of barriers to truly sharing health records, or “We succeeded!” because we are now almost 100% digital.

In my view, it’s more like The Good, the Bad and the Ugly.  

The Good

EHR adoption. The most important development related to healthcare technology is the digitization of health records. EHRs are foundational for other technology-driven innovations including clinical decision support, electronic prescribing, predictive analytics – and the list goes on. The HITECH Act accelerated the industry’s adoption of EHRs because of the financial incentives for Medicare/Medicaid providers that it contained. Maybe it was brute force, but it worked. Adoption of EHRs jumped from a meager 10-20% in 2008 to over 75% adoption in just six years. Adoption of Certified EHRs today reaches virtually every hospital and over 90% of ambulatory physicians.

No other technology has had faster adoption rates — even the things we can’t imagine life without. Not personal computers (8-75% over 26 years). Not the internet (10-75% over 18 years). Not even our highly addictive smart phones (35-75% over seven years). And consider this: when the HITECH Act was passed in 2009, 84% of households already had a cellphone. So, it was high time for EHRs.

Improved Quality and Safety. The ONC’s 2016 report to Congress noted that “systematic reviews have found that 84% of academic studies examining health IT functionalities required under the Medicare and Medicaid EHR Incentive Programs had a positive or mixed positive effect on quality, safety, and efficiency of care.” Since these issues are really what the whole $35 billion or so was meant to address, this statement should be more heavily weighted in our rough calculus of the good, the bad and the ugly. So, this is very good indeed.

2015 Certification Standards. Specifically, I am referring to the requirement that Certified EHRs support the export of common clinical data (now known as the “US Core Data for Interoperability”) using interoperability standards like the Consolidated Clinical Document Architecture (C-CDA) that make data available for care transitions and analytical use. Although this has not completely solved the interoperability problem (see The Ugly), requiring data in conformance to C-CDA is definitely part of the solution.

Establishment of HIEs. The HITECH Act provided the legislative incentive and funding for the creation and expansion of state Health Information Exchanges (HIEs). Funding was used for HIE technology infrastructure as well as to establish governance, consent and policy. Today’s HIEs are providing secure exchange of health information for providers, payers and patients in support of quality improvement, care coordination and public health. In my view, they are a critical national infrastructure designed locally to foster trust and last-mile connectivity. They mostly operate with small staffs and limited financial resources but deliver huge improvements in how healthcare is delivered for their communities.  They will continue to play an important part in the provision of high-quality healthcare data across otherwise separate parts of the healthcare ecosystem.

Growth of the HIT Industry. Remember, the HITECH Act was part of the American Recovery and Reinvestment Act (ARRA), which was intended to jumpstart the economy. The ARRA provided billions of dollars for health information technology and other health-related programs such as medical research, community health centers, and the VA.  It’s fitting that the HITECH Act had a hand in the creation of the healthcare technology sector we belong to, calculated at a market size of $163 billion in 2018 and predicted to be over $441 billion by 2025 (Global Market Insights).

Healthcare Informatics. I was trained as an informaticist and so this one is near and dear to my heart. It was the HITECH Act that directed that assistance be provided to institutions of higher education to establish or expand health informatics education programs “to ensure the rapid and effective utilization and development of health information technologies.” Informaticists are a mixed breed of clinicians and computer scientists who are dedicated to making software-speak the language and meet the workflow of clinicians. And there are more of us now, thanks to the HITECH Act.

Expansion of the ONC. While the Office of the National Coordinator was originally created by George W. Bush in 2004, the HITECH Act cemented its role and functions in 2009. It has a noble goal of recommending technology to ensure “the utilization of a certified electronic health record for each person in the United States.” The ONC is responsible for establishing the strategic plan for a nationwide health IT infrastructure and for reviewing standards and certification criterion.  It’s both inspirational and aspirational to read the duties of the National Coordinator of the ONC as defined in law. To summarize, the National Coordinator is tasked with development of strategy to allow for electronic use and exchange of information consistent with security and privacy, quality improvement, cost reduction, reduction of health disparities, and patient-centered care. Although we haven’t achieved all these goals, simply publishing them as part of our federal strategy is a good thing.

The ONC has recruited remarkable talent into government who combine clinical, policy and business savvy. They’ve gone on to continue to impact the industry. David Brailer, the first National Coordinator, joined a venture capital firm dedicated to health IT investments. His successor David Blumenthal is president of the Commonwealth Fund, which funds research to promote a high-performing healthcare system. Another ONC Director, Farzad Mostashari, founded a leading company for Accountable Care Organizations. Consider the career of Karen DeSalvo. After her role at the ONC, she became acting secretary of HHS. She was just appointed Chief Health Officer at Google, so she will now have a hand in leading Big Tech’s march into the healthcare domain. The current National Coordinator, Don Rucker, is shepherding the rule-making process related to achieving healthcare data interoperability mandated under the 21st Century Cures Act. The HITECH Act is the progenitor of the health information technology component of the Cures Act, which is our next attempt to get interoperability right. Which leads us to The Bad and The Ugly.

The Bad

Physician Burnout. Poorly designed user interfaces, burdensome documentation requirements, quality reporting disconnected from the provision of high quality care, and noisy, duplicative data and metrics generated from EHR data…. EHRs are “the single most important ‘pain point’ confronted by physicians in their practice.” So Meaningful Use, the ACA, HITECH, and ARRA must take some credit for contributing to this pain. My view is that this will change as we liberate physicians from redundant and onerous documentation related to quality reporting and billing. Once we can generate data that can be applied for multiple purposes as a natural byproduct of clinical care, much EHR pain will ease.

The Ugly

We Share Data but Not Meaning. This is an epic failure laid at the foot of the HITECH Act but may have been too ambitious even for $35 billion. We can now physically transfer data, but often its meaning is lost and can’t be effectively ingested and re-used from one system to another. Standards such as C-CDAs have started to create meaningful exchange and enabled humans to interact with more clinical data than ever before. Today, billions of clinical documents have been exchanged! But patients can’t readily put data on their phones. Providers often do not have their clinical decision rules operate on data collected elsewhere (although HIEs have successfully brokered clinical data by collecting it from multiple providers, combining it, and sending it back as a consolidated clinical record).

Many EHRs were designed initially for revenue cycle and then adapted to clinical workflows.  Yet, effective data sharing also means supporting additional downstream use cases (population health analytics, quality reporting) without adding burden (e.g. screen time, keystrokes) to the source users.

Source: ONC’s 2018 Report to Congress

But here’s the good news. Ugly babies can turn out to be beautiful adults. The foundation laid by the HITECH Act and Meaningful Use, especially related to standards like C-CDA and national terminologies, pave the way for the current set of proposed rules under the Cures Act. I believe that use of modern technology (e.g. APIs, FHIR) to pull data into applications and for analysis, mandated patient data access, and legal restrictions to data-blocking will propel the next phase of innovation. These rules won’t solve all the problems of making data truly interoperable – we will need a “second tier” of data, as noted by Google’s former executive chairman Eric Schmidt at his HIMSS18 keynote. But support from the federal front is critical to making the healthcare system finally achieve the promise of the HITECH Act.

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1 Comment

  • Thanks for the excellent summary of how far we’ve come in Health IT and interoperability in the last decade. I especially liked and was surprised by the comparison of the pace of adoption to other key technologies.

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